DISCUSSION

THE STATE OF UHC IN EUROPE

MdM views health under the more holistic prism of health and wellbeing and follows a rights-based approach acknowledging and acting upon social determinants of health such as poverty, racial discrimination, housing, working conditions, etc. This modus operandi reveals significant gaps and challenges in regard to access to health for people living in different geographical areas. What remains more hidden, even to date, is the problems and obstacles different people experience within the boundaries of the European continent itself as well as the reasons behind these barriers. The present report attempts to give a better insight on the profile of people excluded from healthcare in Europe today and the reasons behind their discrimination. The consequences of health inequity in terms of individual and public health are also tackled on the basis of relevant findings. According to the principles of UHC, all people should have access to the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course: “leaving no one behind” and “caring for the furthest behind first”.50 However inequalities prevail across the health sector in Europe today, as the present report illustrates with 25,355 unique individuals visiting MdM programmes instead of public health facilities during 2019–2020. The results of this 2021 Observatory Report shows that out of all people visiting the MdM programmes, the percentage of non-EU/EEA migrants benefiting from the MdM programmes was 74.7%. While slightly reduced, compared to 81.6% in the 2019 Observatory Report, it nevertheless remains high, vividly illustrating the point that these populations are indeed left behind, despite political declarations on the opposite. In that sense, European governments are not adhering to the Covenant on Economic, Social and Cultural Rights and especially the right to the highest attainable standard of health.51 At the same time, the percentage of EU/ EEA migrants among MdM beneficiaries increased, reaching 22.2% in the 2021 Observatory Report as opposed to 15.9% in the 2019 Observatory Report. This implies a cross-cutting deterioration of health services in Europe today and raises questions about the extent to which European states are meeting the healthcare needs of European citizens living in their territory, thus observing Article 16 of the Social Pillar. It is also interesting to note that, out of the total, the percentage of national patients examined by MdM was 3.1%. This indicates fractions and niches of the developed EU health systems that while advanced, they nevertheless fail to provide full health coverage, free of charge, even to their own citizens. Further evidence to this is also supported by the fact that the proportion of nationals increased between the 2019 Observatory Report and the 2021 Observatory Report from 2.5% to 3.1%. Almost one-third of nationals who attended an MdM programme were under the age of 4 (30.3%). High levels of children were also observed among EU/EEA migrants. That is strong evidence of the need to further increase the level, accessibility, affordability, acceptance, and quality of paediatric and family healthcare services in European countries today. Moreover, it stands out as a sad confirmation that national governments do not fully comply with the letter and the spirit of the United Nations Convention on the Rights of the Child that clearly states: “State Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.”52 High percentages of patients with chronic diagnoses (eg, circulatory: 26.1%, musculoskeletal system and connective tissue: 12.7%, and psychological disorders: 10.9%) are evidence of complex cases that require a broader framework of health and social support. Even so, 3.3% reported having access to emergency care only, and a staggering 78.2% reported having no healthcare coverage. Patients with chronic diagnoses require the availability of needs-tailored services and this report presents evidence that governments are not providing access to a sufficient range of services to achieve well-targeted assistance and universal coverage.

COVID-19: CHALLENGE AND MOMENTUM

On top of a European environment already burdened by financial austerity, Brexit and deterrence policies in relation to refugees and migrants’ reception, the outbreak of COVID-19 has come to test our willingness and ability to deliver health for all. The pandemic threatens to undo decades of progress. It has disrupted delivery of essential health services in many countries, stretched resources to the limits, and revealed the impact of decades of underinvestment in primary care and essential public health functions.53 This puts additional pressure on vulnerable population groups with unmet health needs. There can no longer be any question about the links between public health and the broader resilience of economies and societies. COVID-19 has reinforced existing evidence that investments in health have long-term returns, while underinvestment has potentially devastating large-scale global social and economic effects that could last for years. The pandemic is costing the global economy $375 billion a month and 500 million jobs since the crisis erupted.54, 55

50. United Nations General Assembly. (2015).

Resolution 70/1. Transforming our world: the 2030

Agenda for Sustainable Development. Resolution

A/RES/70/1. Paragraph 19. New York, NY: United

Nations. Retrieved 25 September 2021, from https://undocs.org/A/RES/70/1. 51. United Nations. (n,d). International Covenant on Economic, Social and Cultural Rights.

Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966 entry into force 3 January 1976, in accordance with Article 27. Geneva: Office of the High Commissioner for Human Rights. Retrieved 10 September 2021, from https://www.ohchr.org/Documents/

ProfessionalInterest/cescr.pdf. 52. United Nations General Assembly. (n,d). Resolution 44/25. Convention on the rights of the child.

Resolution A/RES/44/25. New York, NY: United

Nations. Retrieved 25 September, from https://www.ohchr.org/en/professionalinterest/ pages/crc.aspx. 53. Universal Health Coverage Day. (n,d). UHC day 2020. [online]. Retrieved 23 September 2021, from https://universalhealthcoverageday.org/results/. 54. Universal Health Coverage Day. (n,d).

Commitments. [online]. Retrieved 23 September 2021, from https://universalhealthcoverageday. org/commitments/. 55. United Nations. (2020). Policy brief: COVID-19 and universal health coverage. New York, NY:

United Nations. Retrieved 23 September 2021, from https://www.un.org/sites/un2.un.org/files/ sg_policy_brief_on_universal_health_coverage.pdf.

MdM ground experience indicates that the most vulnerable populations are traditionally excluded from public national health systems due to their social, cultural, or legal status and are the ones that suffer the most during health crises.56 Populations such as homeless, roma, asylum seekers, migrants, etc, are indeed among the groups of concern regarding COVID-19 from a public health perspective: being unable to properly follow the necessary precaution measures, they are at high risk of getting COVID-19 and also contributing to its transmission. At the same time, COVID-19 has created a new momentum towards prioritising prevention and public health measures for UHC at all levels and striving for a robust, collaborative, global health architecture.

EXCLUSION OF VULNERABLE GROUPS IN HEALTHCARE SERVICES AND LIMITATIONS OF HEALTH REPORTING

The financial crisis, the subsequent political and solidarity “crises” erupting across different European countries in relation to migration, and the outbreak of COVID-19 have created a new level of fragmentation and exclusion and have aggravated access to healthcare for the most vulnerable: unaccompanied children; pregnant women; homeless people without any shelter; undocumented migrants; and the elderly.57 Difficulties in accessing healthcare services have long been more common among certain population groups. In addition, new groups that were not considered vulnerable before, such as young unemployed men or young couples facing housing and job insecurity, a “newly poor” have also emerged.58,59 Within the framework of the 2021 Observatory Report, the reduction witnessed in total non-EU/EEA beneficiaries’ numbers and consultations between the 2019 Observatory Report and the 2021 Observatory Report could reflect the results of movements’ restrictions and lockdowns imposed during the year due to COVID-19 and points toward other, more worrisome developments, namely, the reinforcement of the “Europe fortress” approach, the prevalence of deterrence policies, and the malpractice of pushbacks allegedly conducted by national authorities and Frontex, a practice that directly violates the principle of “non-refoulement” as dictated by the international human rights law.60 The report raises grave and urgent questions about the welfare and health of vulnerable children across Europe. The fact that children – including proportionately higher levels of EU/ EEA migrant children – were seeking healthcare from MdM programmes, and not the national health system, shows European governments are failing to provide them with adequate access to healthcare services. There is also a growing concern for the plight of the increasing numbers of unaccompanied children; for the lack of access to national SRH services mainly regarding non-EU/EEA migrant women that suffer from a double marginalisation (“migrants” and “women”); for the chronic patients and the ones facing mental health issues. The limitations of existing mechanisms to record and monitor access to healthcare services for such groups means that they are not just economically, socially, and politically excluded and disconnected from societal institutions, but also not counted in official data. Thus, they remain invisible in the development of policies and programmes. Capturing them in this report, provides an opportunity for policymakers to address their healthcare needs. Unrepresentative patient populations or missing data can pose significant obstacles when conducting public health research and there continues to be a need for reported data.61 Efforts to increase transparency regarding the quality of healthcare are going in parallel with a call for wider accountability in the health sector. Poor data quality, inaccurate data, inconsistencies across data sources, and incomplete (or unavailable) data necessary for operations or decisions adversely influence future operational plans and effective strategies for improvement.62 Aside from inadequate reporting, a lack of data standardisation regarding the exchange of surveillance data between health providers and public health authorities and between public health entities and civil society organisations prevents smooth coordination and informed decision making among important health stakeholders.63

56. Médecins du Monde Greece. (2020). Médecins du Monde International Network Statement on the COVID-19 pandemic: pandemics do not respect borders. Retrieved 23 September 2021, from https://mdmgreece.gr/en/medecins-dumonde-international-network-statement-covid-19pandemic-pandemics-not-respect-borders/. 57.ELIAMEP. (2013). Fragmentation and exclusion: understanding and overcoming the multiple impacts of the crisis (FRAGMEX). [online].

Retrieved 23 September 2021, from https://www. eliamep.gr/en/project/fragmex/. 58. Zafiropoulou, M. (2014). Exclusion from healthcare services and the emergence of new stakeholders and vulnerable groups in times of economic crisis: a civil society’s perspective in Greece. Soc

Change Rev, 12(2), 25–42. Retrieved 23 September 2021, from https://www.academia.edu/10500386/

Exclusion_from_Healthcare_Services_and_ the_Emergence_of_New_Stakeholders_and_

Vulnerable_Groups_in_Times_of_Economic_

Crisis_A_Civil_Societys_Perspective_in_Greece. 59.Eurofound. (2014). Access to healthcare in times of crisis. Publications Office of the European Union,

Luxembourg[online]. Retrieved 23 September 2021, from Available at: https://www.eurofound. europa.eu/publications/report/2014/quality-of-lifesocial-policies/access-to-healthcare-in-times-ofcrisis [Accessed 23 Sep. 2021]. 60.Office of the High Commissioner for Human

Rights. (n,d). The principle of non-refoulement under international human rights law.

Retrieved 23 September 2021, from https:// www.ohchr.org/Documents/Issues/Migration/

GlobalCompactMigration/ThePrincipleNon-Refoule mentUnderInternationalHumanRightsLaw.pdf. 61.Strongman, H., Williams, R., Meeraus, W.,

Murray-Thomas, T., Campbell, J., Carty, L., et al. (2019). Limitations for health research with restricted data collection from UK primary care.

Pharmacoepidemiol Drug Saf, 28(6), 777–787.

Retrieved 23 September 2021, from https://dx.doi. org/10.1002%2Fpds.4765. 62.Dixon, B. E., McGowan, J. J., & Grannis, S. J. (2011). Electronic laboratory data quality and the value of a health information exchange to support public health reporting processes. AMIA Annu

Symp Proc, 322–330. Retrieved 23 September 2021, from https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3243173/. 63.van Panhuis, W. G., Paul, P., Emerson, C.,

Grefenstette, J., Wilder, R., Herbst, A. J., et al. (2014). A systematic review of barriers to data sharing in public health. BMC Public Health, 14(1), 1144. Retrieved 23 September 2021, from https://bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-14-1144.

HEALTHCARE NEEDS OF AN EXCLUDED POPULATION

HEALTH STATUS

European health systems, stretched to their limits by the pandemic, are becoming more closed, excluding higher numbers of patients and evidently restricting access to health for all, despite political statements supporting the opposite. A “me first” approach, prevailing during the initial phase of the pandemic in relation to masks’ imports and distribution is sadly repeated during the present phase of vaccines’ roll out, clearly indicating that the collaborative approach required in order to achieve health for all has still a long way to go. One in four people reported their general health as “very bad” or “bad” (26.7%). As multiple pathologies have been frequently recorded for each individual, for instance, the incidence of comorbidity is high, it becomes evident that the more complex and difficult cases, the ones that require the existence of a more demanding, wider, and multifaceted framework of support to recover, are practically confronted with limited availability of needstailored services and are thus eventually excluded from access to health as the national health systems and/or the aid programmes put forward by nongovernmental organisations have not been designed to cover such needs. While caution should be exercised as missing data varied across the three groups (EU/EEA migrants, non-EU/EEA migrants, and nationals), a staggering 91.6% of individuals reported living under the poverty threshold leaving no doubt with regard to the significance of poverty as a social determinant of access to health. At least half of the world’s population lacks access to essential health services; more than 800 million people have to spend at least 10.0% of their household income on health care. Out-of-pocket expenses drive almost 100 million people into poverty each year. If we continue with the same pace, up to one-third of the world’s population will remain underserved by 2030.64 The majority of people we saw reported not having healthcare coverage (78.2%). While these figures should be interpreted carefully since missing data varied across the three groups (ie, EU/EEA migrants, non-EU/EEA migrants, and nationals) they nevertheless reveal the fact that access to healthcare equals to acquiring (national) healthcare coverage in European countries. Understandably, nationals have the highest proportion of individuals with full healthcare coverage (17.9%). The issue of national social security number, that is – literally – the ticket for access to state health services has long been debated at EU level under the light of the 2015 migrant reception, when the number of new arrivals of nonEU/EEA migrants to the EU skyrocketed. Sadly, but not unexpectedly, the majority of non-EU/EEA migrants reported not having healthcare coverage (81.1%), followed by 65.1% of EU/EEA migrants. It is also worth noting that a significant 14.0% of EU/EEA migrants did not know if they had healthcare coverage, a fact that highlights the complicacy of health systems in place as well as the need for better informing and empowering vulnerable individuals to pursue their health rights. An outstanding 69.0% of people with permission to reside reported not having healthcare coverage, something that exposes the contradictions and flaws of different national legal and administrative processes that have not been harmonised and are thus failing to achieve a smooth reception and an unhampered integration of foreign citizens. Understandably, a higher proportion of EU/EEA migrants without permission to reside had full healthcare coverage (14.4%) compared to non-EU/ EEA migrants without permission to reside (4.7%).

SEXUAL AND REPRODUCTIVE HEALTH

Of all women seen in MdM clinics 5.9% were pregnant. When asked if they had access to antenatal care, more than half of women (52.7%) responded that they had not accessed antenatal care prior to visiting an MdM programme. Almost half of women (42.9%) had not accessed antenatal care and were in their second or third trimester of pregnancy. These findings clearly demonstrate that UHC is not achieved, as long as necessary sexual and reproductive services are not unconditionally offered to all women in need without discrimination by national health systems across Europe. SRHR is a core issue in MdM programmes and a vital precondition for gender equality and non-discrimination. SRHR is an integral part of the SDGs and the specific needs of women and girls must therefore be prioritised.

PUBLIC HEALTH

A total of 158 different nationalities were recorded, a clear sign of the multicultural profile of the communities that MdM supports. It is of no surprise that the biggest proportion of patients served by MdM programmes were people without a valid residence permit, in other words, without a defined legal and/or citizenship status that actually “opens the door” to access public healthcare services in Europe. While there is no homogeneity across national health systems, practices encountered across the continent are in general not designed to serve the needs of third country nationals and/or underprivileged and marginalised populations. In some countries, access to national health services is provided only on an emergency basis to people without legal documents. This contradicts the United Nations resolution on UHC that states that UHC does not simply equate to emergency care, but includes “promotive, preventive, curative and rehabilitative basic health services needed and essential, safe, affordable, effective and quality medicines”.

64.United Nations General Assembly. (2019).

Resolution 74/2. Political declaration of the high-level meeting on universal health coverage.

Resolution A/RES/74/2. New York, NY: United

Nations. Retrieved 23 September 2021, from https://undocs.org/en/A/RES/74/2.

Non-EU/EEA migrants and marginalised populations tend to be excluded from public healthcare services in the pretext of objective barriers, for example, linguistic, as well as subjective barriers, for example, biases and beliefs. The diversity of nationalities encountered in MdM programmes reveals not only the range of the countries of origin, thus the variety of cultures and possible related barriers to access to health but also the variety of routes and different patterns of migration Europe is confronted with today. The most frequently reported nationality was Côte d'Ivoire at 10.9%, followed by Romania at 9.6%, Bulgaria at 6.7%, and Morocco at 6.2%. Overall, most MdM beneficiaries at 51.9% were of African origin; 31.1% were of European origin, 14.5% were of Asian origin, and 2.5% originated from the Americas. Looking deeper, namely, by sub-region, most of MdM patients were from sub-Saharan Africa (35.2%) and Eastern Europe (20.2%), a fact that reaffirms the role of conflicts and poverty as main drivers for migration while also supporting the scope of climate change as a new, additional reason behind people’s mobility. While extra caution should be exercised with regard to data on children’s vaccination due to a high number of missing and/or non-valid answers, according to the responses received, percentages for routine immunisation range between 42–46%. Though encouraging in terms of access, these percentages highlight additional worries in terms of public health and prevention. Almost half of individuals, 47.5%, in all MdM programmes lived in insecure housing while one in five (18.9%) were roofless or sleeping rough. Adequate and proper housing is not only an undeniable human right but a precondition for healthcare, regular treatment, and support. Accessing healthcare services is often dependent on housing-related paperwork, such as proof of tenancy or proof of address. A higher proportion of EU/EEA migrants were living in roofless situations: 35.1% compared to 19.5% of non-EU/EEA migrants. The fact however that 58.9% of non-EU/EEA migrants report living in insecure housing is also indicative of an unstable and fragile situation people experience when they depend on state and/or civil society aid. Almost half of nationals were either roofless (19.6%) or experienced houselessness (30.7%),65 once more highlighting the results of the widespread poverty that austerity politics and social inequality have underpinned.

65. These figures should be interpreted carefully since missing data varied across the three groups.